Potpourri: Recurrent Hypoglycemia, Valproic Acid Overdose, Vertigo, and Autism

Question: What is the differential for recurrent hypoglycemia?

1. In patients without DM—think medications, alcohol, malnutrition, critical illness, counter-regulatory hormone deficiencies, and tumors.

1. Critical Illness includes end-stage liver disease, SEPSIS, starvation, and AKI/renal failure. In these cases, glucose utilization exceeds glucose intake, glycogenolysis, or gluconeogenesis.

2. In patients with DM—think the above, PLUS diabetes therapy. The key medications include meglitinides, sulfonylureas, or insulin. 

1. Insulin is renally cleared, so an AKI can lead a normal dose of insulin to hang around for longer than normal, causing hypoglycemia

3. Note: Patients with refractory hypoglycemia after receiving dextrose (PO or IV) in the ED require hospital admission. Need to figure out why—and hypoglycemia at home is NOT safe.

4. Remember, in sulfonylurea-associated hypoglycemia, consider octreotide, especially if recurrent. 

5. Review all about Hypoglycemia in Corependium

Question: What’s the deal with a valproic acid overdose?

1. Toxicity can cause—direct hepatotoxicity, Acetyl-CoA depletion, Carnitine depletion, Glutathione depletion, B-oxidation

2. Ingestions <200 mg/kg, usually cause mild sedation. Ingestions >400 mg/kg can cause coma, cerebral edema, and hemodynamic instability

3. If someone comes in with confusion, coma, or seizures, consider Valproic-Acid induced hyperammonemia encephalopathy, which can occur with acute or chronic valproic acid toxicity.

4. Treatment—Hemodialysis (really high level, cerebral edema, unstable, coma, intubation) and L-Carnitine. Especially if hepatoxicity is noted.

5. Read all about this here in Corependium.

Question: What do you mean by dizzy?

1. Please review this article that discusses the modern approach to vertigo. It is important to avoid clinical reasoning that could come back to bite you (e.g. that lack of room spinning means that it is not vertigo). DONT BE FOOLED.

2. This “Timing and Triggers” paradigm is super helpful and makes the dizzy patient so much easier to evaluate!

Question: What do you mean Tylenol causes autism? (it doesn’t)

1. In these...dynamic times, please review and familiarize yourself with the Harvard systematic review that formed the foundation of the Tylenol + Autism claim. Published in Aug 2025. 

2. Remember to review all articles for conflicts of interest, such as receiving $150,000 to serve as an expert witness in Tylenol lawsuits. 

As always, it's a pleasure.

Dillon